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  • Writer's pictureThe Communiqués

Future Leaders Communiqué Volume 6 Issue 1 January 2021

  • Guest Editorial

  • Editorial

  • Guest Commentary

  • Case: “Who cares?”

  • The system is broken!

  • Care of the acutely suicidal patient

  • Comments From Our Peers


We are very pleased to publish this edition, the first Future Leaders Communiqué of 2021. This edition is unique. The case we examine is that of the coroner’s inquest into the death of Melanie Tregonning; a talented illustrator whose suicide was preceded by a series of miscommunications and system failures from the health care community as she repeatedly sought assistance with a mental health emergency.

Our standard practice at the Future Leaders Communiqué is to anonymise the personal details of any patients involved in the coroner’s cases we review. We have not done that in this instance. This is not a decision we make lightly and only proceeded with the family’s express consent. We want this edition to reflect on what we as healthcare clinicians can learn from the coroner’s inquest into Melanie Tregonning’s death, and also to mourn what we have lost. Melanie Tregonning was a gifted artist with a bright future. A sample of her work is included in this edition with the permission of her family, to whom we are very grateful. Melanie’s artwork is unique and engaging. Her graphic novel, Small Things, tells the story of a little boy who feels alone with the worries he has inside, but who learns that help is always close by. It is available to access via her website,

We would like to thank Melanie’s family for not only allowing us to include a number of Melanie’s works of art, but also for sharing their own reflections on the circumstances leading to Melanie’s tragic death. We are grateful to her sister, Violet, for her contribution to this edition. Mental health reform, including timely access to appropriate mental health support for all members of the community, is one of the greatest challenges currently facing our healthcare system. It is important to appreciate the bravery of advocates such as Violet - those who have been deeply affected by deficiencies in our system and speak up to evoke change. It is incumbent upon us as clinicians to heed her reflections, to better inform our practice and prevent similar errors in future.

Our expert commentaries for this edition are kindly provided by Associate Professor Jonathan Knott, Director of Emergency Research at Melbourne Health and Clinical Sub-Dean for Emergency Medicine at University of Melbourne, and Dr Evan Symons, Unit Head of Consultation-Liaison and Emergency Psychiatry at Alfred Health, Melbourne. Associate Professor Knott lends his expertise by describing some actions all clinicians can take to mitigate the risk of error in assessing and managing patients presenting with mental health issues. Dr Symons shares his tips to junior doctors in identifying, supporting and caring for those patients presenting acutely suicidal.

This edition has been made possible by the passion, insightfulness and persistence of our guest editor, Dr Daniel Grose. Daniel is currently an Advanced Trainee in General Medicine at St Vincent’s Hospital Melbourne. He is an aspiring General Physician and Geriatrician, with an enthusiastic interest in the biopsychosocial model of health and disease. Daniel has put huge thought and effort into curating this edition, and we hope that it will act as a valuable resource on this important topic for our future leaders for some time to come.


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